Advanced Pediatric Airway Team-based Learning * ^† ^† Sara Paradise, MD , Aaron Leetch, MD and Garrett S. Pacheco, MD *University of California, Irvine, Department of Emergency Medicine, Orange, CA ^University of Arizona, Department of Emergency Medicine, Tucson, AZ †University of Arizona, Department of Pediatrics, Tucson, AZ Correspondence should be addressed to Sara Paradise, MD at [email protected] Submitted: February 28, 2018; Accepted: March 16, 2018; Electronically Published: October 15, 2018; https://doi.org/10.21980/J8KH01 Copyright: © 2018 Paradise. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/licenses/by/4.0/ ABSTRACT: Audience: While all levels of learner could potentially benefit from this classic team-based learning (cTBL), it is designed for senior emergency medicine (EM) residents or pediatric emergency fellows who are already familiar with basic pediatric airway topics. Introduction: Respiratory complaints are one of the most common reasons that pediatric patients present to the emergency room, with 9.6 million visits for respiratory-related reasons in 2015.1 While many of these visits require only minimal interventions such as supportive care, bronchodilators, or oral medications, the emergency provider must always be prepared in the event of a life-threatening airway emergency requiring immediate intervention. However, identifying and managing these cases may be challenging for residents, especially those with infrequent or seasonal pediatric exposure. While there are many individual articles on topics related to respiratory or airway emergencies, there are few case-based activities for emergency medicine providers available, and these are either simulation-based,2-5 targeted towards anesthesiologists,6 focused on one disease process,7,8 or targeted towards medical students.9,10 Therefore, the goal of this cTBL is to review a variety of unique but complementary life-threatening pediatric airway cases for emergency medicine physicians, including the presentation, workup, and management of each: foreign body obstruction, bacterial tracheitis, status asthmaticus, and post-tonsillectomy bleeding. Objectives: This cTBL covers a variety of pediatric airway emergencies. Therefore, by the end of this cTBL, the learner will be able to: 1) List the signs and symptoms associated with airway foreign body obstructions. 2) State the appropriate management of upper and lower airway foreign bodies. 3) Discuss the symptoms, signs, and management of bacterial tracheitis. 4) Discuss a step-wise algorithm for emergency asthma treatment in the emergency department setting. 5) Identify the potential complications of tonsillectomy and the acute management of post-tonsillectomy hemorrhage. Method: This didactic session is a classic TBL. Topics: Pediatric airway emergencies, airway foreign body, foreign body aspiration, bacterial tracheitis, pediatric asthma, status asthmaticus, post-tonsillectomy hemorrhage. 1 USER GUIDE List of Resources: Linked objectives, methods and results: Abstract 1 Pediatric airway emergencies are infrequently experienced by resident physicians; therefore, a team-based learning activity User Guide 2 which includes a review of multiple presentations and a higher- Learner Materials 5 level discussion of these scenarios may provide enhanced iRAT 5 preparation for clinical experiences. Case 1 involves a pediatric gRAT 7 patient with a history concerning for an airway foreign body GAE 10 ingestion, and reviews upper versus lower airway foreign body Pediatric Airway Pearls 15 diagnosis and management, and therefore achieves objectives 1 Instructor Materials 17 and 2. Case 2 covers a patient with recent croup who now is RAT Key 18 developing worsening signs and symptoms concerning for GAE Key 22 bacterial tracheitis, thus achieving objective 3. Case 4 is a patient with asthma refractory to initial interventions, and reviews the presentation, management, and treatment Learner Audience: Junior Residents, Senior Residents algorithm for status asthmaticus, thus achieving objective 4. Lastly, case 5 is a patient who presents with post-tonsillectomy hemorrhage, and has learners identify the diagnosis, initial Time Required for Implementation: Instructor Preparation: 30-60 minutes managements, and disposition, achieving objective 5. Learner Responsible Content: 0-60 minutes Learners’ critical thinking is probed during the activity through In Class Time: 90 minutes discussion with group members to answer questions, and knowledge is solidified through review of the answers with the instructor. Recommended Number of Learners per Instructor: Depending on group size, only one instructor is required, though it is helpful to have others familiar with the content Recommended pre-reading for instructor: The instructor should primarily be familiar with all cases and to interact with learners during the session. An ideal size for this didactic is 10-30 learners, though it may be completed instructional materials. Optional pre-reading includes: • in larger groups if more instructors are available. Berdan E, Sato T. Pediatric Airway and Esophageal Foreign Bodies. Surg Clin North Am. 2017;97(1):85-91. Topics: doi: 10.1016/j.suc.2016.08.006 Pediatric airway emergencies, airway foreign body, foreign • Al-Mutairi B, Kirk V. Bacterial tracheitis in children: body aspiration, bacterial tracheitis, pediatric asthma, status approach to diagnosis and treatment. Paediatr Child asthmaticus, post-tonsillectomy hemorrhage. Health. 2004;9(1):25-30. • Camargo C, Rachelefsky G, Schatz M. Managing asthma Objectives: exacerbations in the emergency department: summary This cTBL covers a variety of pediatric airway cases. of the National Asthma Education and Prevention Therefore, by the end of this cTBL, the learner will be able Program Expert Panel Report 3 guidelines for the to: management of asthma exacerbations. J Emerg 1. List the signs and symptoms associated with airway Med. 2009;37(2 Suppl): S6-S17. doi: foreign body obstructions. 10.1016/j.jemermed.2009.06.105 2. State the appropriate management of upper and • Lau AS. Post-tonsillectomy bleed. ENTsho.com. lower airway foreign bodies. https://entsho.com/post-tonsillectomy-bleed/. 3. Discuss the symptoms, signs, and management of Updated September 29, 2018. Accessed September 10, bacterial tracheitis. 2018. 4. Discuss a step-wise algorithm for emergency • Fox S. Post-tonsillectomy hemorrhage. Pediatric EM asthma treatment in the emergency department Morsels. http://pedemmorsels.com/post- setting. tonsillectomy-hemorrhage/. Published August 17, 5. Identify the potential complications of 2012. Updated July 23, 2016. Accessed September 10, tonsillectomy and the acute management of post- 2018. tonsillectomy hemorrhage. Learner Responsible Content (LRC): Prior to the activity, send out the materials below to learners for suggested reading/listening: 2 USER GUIDE • Moses S. Pediatric assessment triangle. Family Practice enhanced answers in case of questions, and not all material Notebook will need to be covered. https://fpnotebook.com/ER/Peds/PdtrcAssmntTrngl.ht 7. Hand out post-test learning sheet. m. Published June 1, 2015. Accessed September 27, 2018. Evaluation: • Seth, D, Kamat, D. Foreign-body Aspiration: a guide to In the pilot session of this cTBL, 9 out of 18 participants (all EM early detection, optimal therapy. Pediatrics Consultant residents, varying from intern to third year residents) Live. completed the post-TBL survey. Overall, this session was rated http://www.pediatricsconsultantlive.com/allergy/forei as “outstanding” (Likert 5/5) by 5 and “excellent” (Likert 4/5) by gn-body-aspiration-guide-early-detection-optimal- 4 for a weighted average of 4.56. Eight found the activity therapy. Published January 2, 2007. Accessed March “highly engaging,” and all participants wanted to repeat the 26, 2018. activity in the future. Negative feedback surrounded the desire • Ibrahim AF. Pediatric Asthma. CDEM Curriculum. to have more time for the activity. As a result of feedback, we https://cdemcurriculum.com/pediatric-asthma/. suggest monitoring the time spent on other portions of the Accessed on May 25, 2018. activity closely to allow for more discussion, and allotting at • Fox S. Post-tonsillectomy hemorrhage. Pediatric EM least 90-120 minutes for completion. Morsels. http://pedemmorsels.com/post- tonsillectomy-hemorrhage/. Published August 17, References/suggestions for further reading: 2012. Updated July 23, 2016. Accessed September 10, 1. McDermott, KW, Stocks, C, Freeman, W. Overview of 2018. pediatric emergency department visits, 2015. HCUP statistical brief #242, August 2018. Agency for healthcare Results and tips for successful implementation: research and quality (AHRQ), Rockville, MD. Prior to the session, the instructor should prepare materials: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb242- • One individual readiness assessment test (iRAT) per Pediatric-ED-Visits-2015.pdf. Published August 7, 2018. learner. Accessed September 21, 2018. • One group readiness assessment test (gRAT) per group 2. Friedman S, Tozzi M, Siems A, Carey A, Moerdler S, Zackai (recommend 3-5 learners per group). See gRAT section S. Simulation of airway management for the pediatric for how to prepare the gRAT. resident. MedEdPORTAL. 2014; 10:9881. doi: • One group application exercise (GAE) per group 10.15766/mep_2374-8265.9881 (recommend 3-5 learners per group). 3. Rogers A, Di